Preoperative Management of Antiplatelet Agents for CABG Surgery Patients: A Prospective Cohort Study Focused on P2Y12 Inhibitors

Abstract

Dual antiplatelet therapy (DAPT) using aspirin and ticlopidine, a thienopyridine P2Y12 inhibitor, was introduced, decreasing the rate of stent thrombosis to about 1%. Continuation of dual antiplatelet therapy (DAPT) until Coronary artery bypass graft (CABG) increases the risk of excessive perioperative bleeding, transfusions, and re-exploration for bleeding as shown in RCTs observational studies and metanalyses. Therefore, it is recommended that the P2Y12 inhibitor should be discontinued whenever possible before elective CABG. For clopidogrel, it was shown in the CABG sub-study of the CURE trial that discontinuation ≥ 5 days before CABG did not increase the risk of bleeding complications. For prasugrel, a longer time interval (7 days) is recommended due to the longer offset time compared to clopidogrel. In a single institution Dutch registry encompassing 705 consecutive patients who underwent isolated on-pump CABG, ticagrelor discontinuation > 72 h and clopidogrel discontinuation > 120 h before surgery were not associated with an increased risk of bleeding-related complications. Prospective data were collected on 150 consecutive patients who were admitted with ACS (Acute coronary syndrome) for CABG from 1 st October 2017 onwards. Elective admissions for CABG were excluded. There was a significant delay in between stopping and the day of Surgery in multiple patients. There were 25 patients who were admitted with ACS for CABG and they were without clopidogrel for more than 10 days, 20 patients stayed without Ticagrelor preoperatively. From this study, it was evident that the guideline was partially met. Appropriate stopping of P2Y12 inhibitors should be considered before surgery according to the guidelines to achieve successful perioperative haemostasis.

Approach of Withholding P2y12 Inhibitors for Urgent Coronary Artery Bypass Grafting in Diabetic Patients With Acute Coronary Syndrome

“…16 Hence, ACS patients usually receive dual antiplatelet before undergoing coronary angiogram, which mandates to delay bypass surgery (in needed) at least 5-7 days, as wash out period before surgery, our study shows by holding P2Y12 inhibitors help to reduce post-operative hospital stay and delay in surgery and reduce cost burden on public hospitals. 14,17 Limitations: This study has some epidemiologic limitations. As it is a retrospective study, selection bias may play a role.…”